Reducing Complications with Intensive Treatment

by Ronald Chusid, D.O.

In 1993 the landmark Diabetes Complications and Control Trial was published, showing that intensive control of blood sugar in Type 1 diabetics reduces the risk of long-term complications. During the second half of 1998, major studies were published which contained similar encouraging news for Type 2 diabetics. These studies showed that intensive medical treatment can reduce complications and improve quality of life.

The most significant study on Type 2 diabetics was jointly released last September in two journals, The Lancet and the British Medical Journal. The United Kingdom Prospective Diabetes Study followed over four thousand newly-diagnosed Type 2 diabetics for twenty years to evaluate the effects of intensive treatment. The intensively treated group had fasting blood sugars reduced to 108Brepresenting even tighter control than the American Diabetes Association=s goal of 120. The most impressive results were seen in over-weight diabetics treated with Metformin (Glucophage). Patients treated with Glucophage showed a 36 percent decrease in all causes of death, and a 39 percent reduction in heart attacks.

Out of this group, 1148 diabetes with hypertension were further studied to show that treatment of hypertension was critical in reducing mortality from diabetes. Their goal was a blood pressure less than ¹⁵⁰/₈₅. Other studies have shown further benefit in lowering the blood pressure to ¹³⁰/₈₀Band even lower when there are early signs of kidney damage. They found that it often took three or more blood pressure medications, and more frequent doctor visits, to achieve these goals. Patients who had tighter control of blood pressure showed a 32 percent decrease in deaths from diseases related to diabetes, a 21 percent decrease in risk of heart attacks, a 44 percent decrease in risk of strokes, and a 37 percent decrease in diabetic retinopathy.

A study published in November in The Journal of the American Medical Association showed that Type 2 diabetics treated with a combination of diet and medications to accomplish better control of blood sugar showed improvements in quality of life. Patients treated with Glucotrol XL were compared to patients treated without medications. After twelve weeks, the group who had reductions in blood sugar with medications reported both feeling better and having improvements in intellectual function. They also found that the patients being treated with medications were more likely to keep their jobs and missed work less often.

Many studies, such as the Cholesterol and Recurrent Events Trial (CARE), have shown that cholesterol-lowering drugs reduce the risk of heart attacks. The degree of reduction in heart attacks is greater than can be explained by reduction in cholesterol alone, suggesting that these medications have additional beneficial effects. A study published in December in Circulation went back over the CARE study data to evaluate the effects on diabetic patients included in this study. Out of the greater than four thousand people in the original CARE study, 586 had diabetes. They found that in diabetics with average cholesterol levels who have had a heart attack, using Pravachol decreased the risk of a second heart attack by 25 percent. The risk of requiring angioplasty or bypass surgery was reduced by 32 percent. Current recommendations are to reduce LDL cholesterol to under 100 in people with known heart disease, as well as in people at high risk of developing heart disease, including diabetics. Studies such as this are being used to suggest that all diabetics might benefit from lipid-lowering medications, even if their cholesterol is not elevated.

The overwhelming evidence that intensive control of diabetes can reduce death and disabling complications, and improve quality of life, makes it more regrettable that the majority of patients with diabetes, hypertension, and hyperlipidemia are not receiving aggressive enough treatment to reduce long-term complications. While rationing of health-care by HMO=s is partially responsible for diabetics receiving inadequate care, studies I reviewed in a previous issue of The Voice showed that diabetics in both HMO=s and traditional health plans frequently fail to receive the degree of care needed to reduce long term complications and death from these diseases.

Dr. Chusid has practiced Internal Medicine in Muskegon since 1985, and has held positions including Chairman of the Department of Medicine and Chairman of the Critical Care Committee at Muskegon General Hospital. He is also an Assistant Clinical Professor of Medicine at Michigan State University, Medical Director of IHS Home Care, and a member of the Council on Complications of the American Diabetes Association.

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Posted May 15, 1999